Wednesday, February 15, 2006

Logged for future reference 1

A couple of letters which appeared in the ST Forum this week seem to me to be worth noting, namely this one from a patient, and this one from Dr Thirumoorthy.I reproduce them in full for future reference because I expect replies to be made over the next few days.

Are subsidised patients treated by specialists?

I WAS relieved to note that the committee on ageing has recommended, among other things, topping up Medisave accounts so that the aged need not worry too much about medical costs.The ability to pay for medical expenses is only one aspect of ensuring good medical care for the aged. More important is quality and access to specialists for chronic medical conditions.

Most of the aged get medical care at the polyclinics, which may refer them to specialists.

This sounds good but as subsidised patients, do they actually see a specialist or just a medical officer at the specialist outpatient clinics (SOC) in the hospitals?

The truth is that most of them are seen by a medical officer and not a specialist.

The current practice is that polyclinic referrals to the SOC are made by a medical officer who decides whether specialist referral is necessary.

This results in a long waiting time at the specialist clinics.

To get a quick appointment with a specialist, one must be upgraded to be a private patient, who will be charged private rates for the consultation, tests and medicine.

I note that the hospitals provide different standards for subsidised and private patients.

The specialist clinic for private patients has well-appointed waiting areas and expensive decor, while the clinic for subsidised patients has plastic chairs in a cramped room.

As a subsidised patient, I was privileged to be treated by a very senior consultant during my regular visits until two years ago.

Since then, although my appointment was made under the consultant's name, I was attended to by a medical officer.

The reason, I was often told by the nurse, was that the consultant was busy. What's worse was that I was charged a consultant's fee.

To me, good quality medical care and equal treatment at hospitals are more important than just having the money to pay for medical services required by elderly folk.

Logistically (and logically) speaking, one cannot expect the specialists to see every single patient whether paying or non-paying; he/she would end up spending every hour of everyday at the specialist clinic.

TPTB need to figure out a way of ensuring that the care given to subsidised patients are up to par (either by way of supervision or reviews by specialists or whatever process that is most effective for each respective institution).

I always felt very strange when I was sitting in specialist outpatient clinics as a veyr young medical officer seeing referrals from polyclinic doctors who were my seniors.

Of course the system was that we should consult the registrar or consultant when we had doubts. But you should see the queue of junior doctors at his door waiting to ask him questions. All this led to slow downs and delays in the clinic.

Usually the clinic patient appointment lists would be based on the number of rooms/doctors available. Eg say there was 1 consultant for the morning and 6 medical officers, then they would have lists for 7 rooms. Each room could take about 30-40 patients. But in reality if all 6 medical officers were young and inexperienced, effectively you only have ONE doctor seeing 280 patients! Imagine the wait!

Well realistically I accepted that this was the reality of the subsidized patients.

Then I found out that in some private patient clinics in the public hospitals (ie A class patients) I was also running the clinics as a senior medical officer. Sometimes the consultant was busy in the operating theatre, sometimes it was to help him deal with the heavy load of paying patients. But each time the patients were unhappy seeing me and I could understand why because they wanted to see a consultant. Fair enough the final charge was cheaper but that is besides the point isn't it? Paying patients are there to generate income for the hospital. Paying pateints pay to expect a consultant seeing them. So imagine the horror when you turn up and a medical officer sees you at the paying class clinic.

In principle that is wrong. But it goes on all the time. Which is why as a GP I always recommend my patients who want to be paying class patients to go to the private hospitals. At least the chances that they see a real consultant are almost 99.99%

Then why not call a spade a spade instead of hookwinking poor Mr. Henry Lim who thinks he is seeing a specialist when in fact he is seeing a medical officer who knows as much about specialised medicine as the greenhorns in the polyclinics?

When you see someone in Gleneagles Medical Centre or Mt. E, you see an ex prof, associate prof. or a senior consultant. No two ways about it. And they are real! Just look at their long list of credentials! Fellow of this, fellow of that. It's enough to bedazzle you and get you on the road to recovery pronto!

The episode with your friend's relative shows that it is better to get a diagnosis in the private sector and if the patient cannot afford private treatment, get it in the public sector with a full report on his health problem shoved under the nose of the MO to get action done real quick.

There have been countless instances in the past where wrong diagnosis have been made in public hospitals.

If a patient is seen by an MO and this MO doesn't have the faintest idea as to what is wrong, do you think it likely that he will go and ask his consultant or the Head of department. If he does that, the assessment of him won't be very optimistic wouldn't it? So what does he do? He just coasts along and with trial and error finds out what is wrong. In lots of cases, that may just be too little, too late.

I've heard a friend tell me this. He is a surgical trainee. Many times they are asked ot do lots and lots of operations. Sometimes they start off on their own for the very first time performing the operation. Their consultants say it's good training for them. You do more you learn more. You make mistakes, you learn from them.

The point however is conscience. What does your conscience say when you are at the operating table doing an operation for the first time and you make a mistake? What do you call that? A learning experience? But in some cases it means the patient losing his voice forever. Is that ok? Well some surgical trainees I know say, well it's a known complication of the operation so it's not that big a deal. Well at consent taking what is told to the patient? Are they told " this operation will be done by a medical officer performing it on his own for the very first time. And the risks of complications are X %"

In reality they are told the risks are <1% but those figures are for experienced surgeons. Would you sign the consent form if you were told the risk was 10% because it was going to be a first time surgeon?

Conscience. Sadly the truth is, the training system is designed such that the brave and the bold excel. Conscience is viewed as a weakness in surgery.

The problem you highlighted sounds like a chicken and egg thing. If you never have your first time dealing with it how then do you get real experience? Isn't this a reality that some patients become 'training' material ???

I think conscience can work both ways depending on how you deal with it. A person can either be so distraugth with his mistake that it incapcitate him to move on further. If not one might be spurred by his consciences to do his best for the patients. I guess it takes a certain kind of character to be a surgeon.

Several years back, went to GP clinic to have the jab against chicken pox. he broke the needle when trying to extract the vaccine from the container!

Then I had a ganglia cyst on my wrist. Was referred to a private hospital (General Surgery). Apparently, the procedure was not properly done as the cyst came back 1 month later and I was subsequently referred to an orthopaedic (a registrar)at the hospital beside AYE. The 2nd doctor was nicer and approachable.

Was referred to him by my gynae for diabetes and all he keeps talking abt how successful his patients were in controlling their condition under his care.

After all his grandfather stories, he got his nurse to test my glucose level, before leaving I was asking him how abt my diet, what should I avoid,etc. Any diet plan, is he going to work out for me. His promise me one would be ready during my next visit.

He told me to see his nurse and she would explain to me. You know what, the nurse told me to eat half of whatever I am eating, that should be fine.

Two weeks later, asked for my diet plan, he answered that he is still working on it.

Is it that tough for him to draft out a diet plan, since he is a specialist, or am I asking for too much, shouldn't he be educating me instead of bragging abt his patient's success. I wonder??? is it his credit or his patients.

After my second visit, decided that I am not going to waste my money on his type of doctor.

So what if you have a diet plan but it is not individualized for you? So much so it is totally not practical for you to follow? What's the point? Your main aim is to have your glucose level under control. Any diet plan should be worked out in discussion with the patient, involving him/her in the decision process.

How to get the right one? Ask around. Ask your GPs for a recommendation. They should know because they are in the loop and know who the quacks are.The REAL specialists in each of the branch of specialisation in Singapore, you can count on the fingers of both hands.

Do you view it as a specialty in its own right? Eg US Board certified family physicians, Fellows of the Royal College of General Practitioners, and Fellows of the Australian College of General Practitioners.

I know many specialists outside of family medicine in Singapore do not view it as a specialty.

Personally I used to be one of these skeptics. However having had to prepare for exams and been in General Practice I think it is a specialty in its own right.

If done correctly there are quite a number of things that the GP can perform without having to refer to the specialist and increase costs and inconvenience the patient. One of the very important roles of a GP include preventive health care and screening.

I can still understand why you would feel Family Med as not a specialty. Especially so in Singapore.

The concept of Family medicine denotes generalization. So isn't the GP already practising family medicine? If I have a serious physiological problem , my good ole GP can advise me what to do and which specialist to consult for a good second opinion.

And I'm not going to pay specialist fees for a GP consultation!

Some docs. wanting to add more initials after their names, take some dermatology diplomas but that doesn't make them dermatologists! And I've see some calling themselves designated "factory doctors"! What the hell is that?

I think "Family Medicine" should be recognized as a specialization in S'pore.

Sometimes, the specialists are "too specialized" such that they are too 'myopic' when treating a case.

On the other hand, the good family physician should have a wholistic view in taking care of the patients, i.e. comprehensive medicine emphasizing family, psychosocial problems, in preventive care, geriatric care and management of chronic diseases, etc.

I think we should highlight to the relevant authorities that our GPs are "underemployed", i.e. we are not maximizing the potential of this group of talents. Doesn’t make economic sense to make them go thru 5 yrs of medical school + another 5 yrs of rigorous training/rotations in different specialties just so that they can dispense cough syrup and panadol for the rest of their useful career life. At the very least, this group of professionals are supposed to be the top few % of their respective cohort, surely they can contribute more to society.

It’s good to see that some pple in the FM fraternity are making efforts to make things happen… making progress bit by bit. Keep it up. : )

A lot of specialists know nothing beyond their specialty. Don't get me wrong. I would go to a cardiologist if I had a heart attack. A neurologist if I had a stroke. But when it comes to having a good competent doctor who can advise you COMPETENTLY (not that of a medical student) regarding common problems in the fields of Cardiology,Gastroenterology, ENT, Respiratory medicine, Neurology, Endocrinology, Psychiatry, Orthopedics, Dermatology, Obstetrics and Gynaecology, and Pediatrics, you would be hard pressed to find a specialist who can do that who is not a Family Medicine specialist.

Try talking to the psychiatrists about high blood pressure. Or the cardiologist about your insomnia. See what you get.

Now I know people like uglybaldie will say that they could easily go see a specialist for every little thing they need. They are all in town, just a short ride on the MRT or drive from home. Affordable, convenient, and accesible. Got a bad cough, go see my respiratory physician. Got chest pains? Go see my cardiologist. What for see the Family Medicine specialist? Or better yet, pregnant? Better DON'T see the Family Med specialist!

But therein lies the real reason why Family Medicine is not valued as a specialty in Singapore. Or for that matter good GPs who know more than just treating cough and colds and diarrhoea.

You see in Singapore it's small and connected. Specialists are just round the corner. GPs are all over the place. Who the heck needs their GP to know how to manage status epilepticus when the hospital A&Es are about 5-10 minutes away by road?

However in other countries, this is not the norm. In some places, eg in the outback or in certain suburbs, the presence of a well trained General Practitioner is essential.

If people in those areas thought like uglybaldie, they would end up having to travel hundreds of miles each time to see their specialist. And by the time they got an appointment to see them, they might be already well or dead. Let's not forget the cost.

So the sad truth is this. There is a place for a specialty called family medicine. In fact I would say it is a rather challenging prospect to be a jack of all trades and yet a master of none. When I mean jack, it isn't good enough to just know a bit, but really be able to manage competently relatively common conditions within different specialties. Regrettably, Singaporeans don't think this is required of their GP. And frankly many GPs also know this and choose to concentrate on certain specific skills eg aesthetics, subutex etc which would help their clinic business survive or prosper.

Personally I accept the realities of Singapore but I don't have to like it.

As a layman, you cannot depend on "Dr Google" all the time. Sometimes you get information overload, and get paranoid from reading all the symptoms listed and then form your own "informed" conclusion. Sometimes, you can't find any information at all, and you really need to discuss with the doctor to find out what's going on.

If problem can be managed at the primary care level, then the hospitals and specialists won't be overloaded: